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Alcoholism

Writing a blog is an entirely new experience for me, and twitter is an even newer experience. I tell myself that I’m young, I should be savvy with these social media forms. However, twitter is something that I just can’t get used to. Once something starts trending, it quickly becomes the only topic on everybody’s mind. And when a patient comes in to the clinic/office to discuss a twitter subject, it can be hard to keep my composure.

A recent journal article published in ‘Scientific American’ titled, LSD Helps to Treat Alcoholism, has been trending in every subject related to alcoholism. It has come to the point that I feel it necessary to add my two cents to this ridiculous subject of LSD as a means to cure alcoholism.

I created this animation to add my two cents

While the journal article is new, published on March 9th 2012, the data is from the 1960’s. The article uses this data in a retrospective meta-analysis to determine if there are any new conclusions that can be drawn when the data is looked at differently. Usually a researcher will have a new hypothesis to test and he/she will use the old data to answer the question. This is a common research procedure and it’s absolutely legitimate.

In this particular article, the authors combined multiple studies that were done in the 1960’s to increase the total number of people in their new study. The purpose of having more people is so that there will be a greater likelihood that the conclusions/results will be similar to the general population. This essentially increases the statistical power and strength of their new study.

The new study determined that people receiving LSD reported lower levels of alcohol misuse. As per the article, “59% of people receiving LSD reported lower levels of alcohol misuse, compared to 38% of people who received a placebo.” When taken at face value, it appears that this is a clear indication that LSD decreases peoples use of alcohol.

What people on twitter don’t consider or realize are the confounding variables. Maybe the subjects reported lower levels of alcohol misuse because they were so wasted from the LSD that they couldn’t even find the liquor store. Or maybe they were so busy trying to obtain more LSD because it was so addictive that they forgot about their alcohol craving for the time being. These are oversimplified alternatives, but such factors must be considered before people come to the conclusion that LSD should be used to treat alcoholism.

The best thing about this blog is that everybody that I have met here has a much more profound understanding of addiction. You know that there is no such thing as a silver bullet to rid the craving. The only way to overcome it is through strength from within. The means that you find that strength is unique to each of you. And that is why I truly enjoy every person here.

Note: Mrs Demeanor did a good job of bringing my attention to a mistake in this post. I make the association of LSD being addictive, when in fact the research shows that LSD is not addictive.

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I have never met two active alcoholics that are the same. Although their lies and deceit can be predictable, there will always be a spectrum of personality characteristics that will differentiate each person. You might argue that aggression would be a common trait seen in alcoholics, but I would have to disagree. Horatio, for example, is rarely found exhibiting aggressive behavior when he is loaded up (this may be because all of his aggression is directed inward).

The Diagnostic and Statistical Manual (DSM IV) has historically divided alcohol abuse patterns in to either alcohol abuse or alcohol dependence. In short, the individual that succumbs to alcohol abuse has a life that is not as impaired as someone with alcohol dependence. The latter individual will be so affected by the substance being in their system that they will demonstrate physiological dependence on the drug i.e. tolerance and withdrawal.

Many in the mental health community further argue that the alcohol dependent patient can be qualified as either of two types. I personally disagree with having two nice and neat categories for the same reason that I don’t feel that people with alcohol addiction can be minimized to having only a narrow spectrum of personality traits. However, it is good to discuss this topic since it brings up common arguments.

The main areas of focus that differentiate the two groups include:
Genetic predisposition
Age of onset
Pattern of onset
Gender
Severity
Personality traits
Risk of abusing multiple drugs.

Type 1
There is less evidence of a genetic predisposition in this patient. Their drinking pattern is usually attributed to events in their life such as losing a job, financial hardship, or stressors at home. The use of alcohol in this group is to assuage the anxiety produced in their life, however, this behavior acts as a positive reinforcement which quickly leads to dependence. The ratio of males to females in type 1 is equivalent, and the severity of alcohol dependence is less as compared to type 2. The personality characteristics commonly seen in type 1 include a tendency to feel anxious, shy, pessimistic, sentimental, emotionally dependent, rigid, reflective, and slow to anger.

Type 2
There is more evidence of a genetic predisposition in this group. The onset of heavy drinking is often before the age of 25. Their pattern of drinking is not necessarily related to stressful events because they commonly drink regardless of the situation. This group is predominately composed of men and often there is a history of fights and arrests. The degree of alcohol dependence is severe as well as a greater risk of abusing other drugs. Type 2 is associated with people that usually don’t experience guilt, fear, or loss of control over their drinking. They tend to be impulsive, aggressive risk takers, quick-tempered, optimistic and excitable.

After reading this, it may be hard not to think that the point of this post was to fit each person neatly in to a single category. That’s actually quite the opposite of my thoughts. It’s more important to realize that there are some similarities between alcoholics. We may find ourselves relating to one type, or the other, or to both. You are a unique individual, and it is better to understand yourself outside of criteria or characteristics.

Through the motivation of helpful and caring people like Jen, Heidi, and Eden I attended my first AA meeting on Sunday. It surpassed many of my expectations; however it ruined others and left me slightly dumbfounded.

My imagination, with the help of television and movies, painted a picture in my mind of what an AA meeting would be like. It portrayed a room filled with people that obviously looked like addicts; unkempt appearances, borderline offensive hygiene, and at least one person emitting a radiance of booze while swaying back and forth in his chair, balancing on the line between falling forward to the ground and staying in the seat.


You should ignore the video if you only know Bob Saget as Danny Tanner from Full House.

My imagination laughed at me as I entered the room. One look around made me realize that I was deceived. The majority of the members were clean, well kempt, and looked healthier than my medical school classmates. Skeptical, I scanned the room again for the person that showed up with a pint of liquor in his/her system. My imagination rationalized that they must have not shown up today, for certainly you can’t have an AA meeting with 100% sobriety. To say the least, I’m still discouraged by its elaborate depiction of this clean and encouraging environment.

After walking through the threshold and soaking it all in, I found a seat near the back where I assumed the newbies were relegated to. Upon finding my spot, I was immediately welcomed by an older gentleman, John, whom was eager to invite me in and listen to my story. I explained everything that you already know about me i.e. intrinsic interest in addiction, Horatio, and an interest in learning from the people that have the greatest depth of knowledge and widest breath of experience in alcoholism, you.

John and I hit it off and he had a great story that ended in him picking up alcohol counseling after retiring from the school system and being happy and sober for the past 27 years. He introduced me to his friends in the meeting who were equally as welcoming as John. As the meeting got underway, I reprimanded my imagination again for feeding me lies.

It was an open discussion that began with the storytelling of one member’s lifelong battle. This was followed by comments from the audience about how they could relate and included a glimpse of their own story which allowed me to capture a little bit of each person in the room. I would be lying if I told you that I did not relate to the thoughts and expressions in the words that I heard.

I found myself intrigued by a discussion on dealing with life events by using alcohol. Many of the members agreed that at one time or another they used alcohol to squelch negative feelings, even if it was as minor as a bill in the mail. This brought my thoughts back to college years. I couldn’t ever comprehend the thought process of the one or two friends that after breaking up with a boyfriend/girlfriend would announce to the world, “I need to get drunk!” Why is it that people want to get drunk when that is the least effective remedy for such an ailment? In fact, alcohol tends to make it worse because the person inevitably makes a bad decision that night. Taking an already emotionally laden person and adding alcohol is like throwing gasoline on a flame. My hope would always be that the night would end in crying over the person rather than the late night vandalism of his/her house.

As the discussion continued, I was struck by another gentleman’s comment on hitting bottom. A rough rendition of his words was, “I thought I hit rock bottom 20 years ago, but I was wrong. Many years later I found out that at the level I thought was rock bottom there was still an elevator that went even deeper to the sub-basement.” This is a subject that I’ve been thinking about tremendously when it comes to Horatio. What will his rock bottom be (or sub-basement)? I know that I can’t force him in to sobriety. The hardest part may be that the only thing I can do is watch and wait for that day. Will it be when he loses his house? Maybe his addiction will take him as far as living on the streets before he’s finally ready to change for good. I have been mentally preparing myself that one day I may have a homeless brother.

As the hour came to an end, I expressed my appreciation to John for taking me under his wing in a place I would have otherwise been lost. Knowing my interest in learning, he informed me about an AA meeting oriented to young addicts (under 25). I look forward to the discussion I will hear there, as well as at my first Al-Anon meeting.

My hardheaded brother (not Horatio) recently appeared in front of the judge to discuss a DUI. This is his third DUI, of which the last two were within a 5 year period. My family and I were expecting the book to be thrown at him which would ensue in a hefty sentence on top of the lengthy restricted license and weighty fines. This is not what happened. His lawyer provided my brother with a ‘Get Out of Jail Free’ card (the card wasn’t actually ‘free’ considering the lawyer fees) which allowed him to skate by the penal system and subsequently not learn from the serious infraction.

This post by earlyrecoveryblog does an excellent job of depicting the depth of denial that addiction burrows into the addict’s subconscious mind. Much like the incidents in the author’s life, the slap on the wrist that my brother received was not enough for him to change his ways. I just hope that he doesn’t seriously hurt somebody before realizing the ramifications of his actions.

earlyrecoveryblog

I remember shoveling mud out of a drainage ditch in an elementary school in Pacifica. It was part of the Sheriff’s Work Program that followed DUI school. I remember not trying very hard. I remember parking near the sheriff station with my temporary license, or my suspended license, remember not being sure which it was, and panicking as I pulled away at the end of the day, waiting for sirens.

It’s been coming up a lot lately, in meetings. Stories of rolling the car, twice, and trying to start it and drive on. Of failing to start it and falling asleep. Of sideswiping semis and walking away.

There were many dark nights.

I’ve been reminiscing about my first AA meetings, the ones I went to when I first started trying to get sober, when I was in and out of the program, a few years ago. But I’ve been forgetting:…

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The Diagnostic and Statistical Manual (DSM) is published in order to have a standardized language in the mental health community. Any change to a classification or criterion of a diagnosis is fretted over and fought over for months and years. There is a diagnosis that will be changing which must be discussed.

In May of 2013 the fifth edition of the Diagnostic and Statistical Manual (DSM V) will be dispersed. This publication will essentially eliminate two diagnoses from its predecessor. The classifications of alcohol abuse and alcohol dependence will be replaced by the term, Alcohol Use Disorder.

Alcohol Use Disorder is derived from many of the same basic premises of the two terms it eliminates. The most important of these include: increasing tolerance to alcohol, withdrawal symptoms if alcohol is stopped, larger amount of time spent procuring alcohol, and daily activities are impaired by it. Below is the full diagnostic criteria.

Alcohol Use Disorder
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:
  1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
  2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
  4) Tolerance, as defined by either of the following:
     a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect
     b) Markedly diminished effect with continued use of the same amount of the substance
  5) Withdrawal, as manifested by either of the following:
     a) The characteristic withdrawal syndrome for the substance
     b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
  6) The substance is often taken in larger amounts or over a longer period than was intended
  7) There is a persistent desire or unsuccessful efforts to cut down or control substance use
  8) A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
  9) Important social, occupational, or recreational activities are given up or reduced because of substance use
  10) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  11) Craving or a strong desire or urge to use a specific substance.

The degree of severity is determined by the number of criteria that the patient meets:
Moderate if he/she meets 2 to 3 of the criteria.
Severe if he/she meets 4 or more of the criteria.

The diagnosis is further broken down in to whether or not the patient is physiologically dependent on the drug. Physiological dependence is determined to be evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present).

Thus, a diagnosis may look like:
Alcohol Use Disorder, Severe, With physiological dependence
or
Alcohol Use Disorder, Moderate, Without physiological dependence

The most interesting part for most that read my blog is that the DSM V will define the stages of recovery. I will have to elaborate on them in a different post, but I can list the categories here:

Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment

John Marsden, a very well established Australian writer with a penchant for alcohol, delves in to the depths of alcoholism. Utilizing the saying, it takes one to know one, he creates a knowledgeable documentary. Below, I reiterate some of his thoughts because I find them to be particularly interesting.

I’ve heard many stories, as well as my own, of having a first drink in the teenage years. It’s shocking to see experiments in this film demonstrate that teenagers, as compared to adults, are better able to handle the same dosage of alcohol. Even when performing tasks, the teenagers are less hindered by the intoxication of alcohol.

He also brings up a great question that I often find ruminating in my head. How many people truly consider the damage that alcohol does to their body? I often discuss this with people who have already had the realization that he or she is an alcoholic. I find it refreshing that the majority of individuals that are aware of being an alcoholic, are also cognizant of the negative impact that drinking has on the body. However, I am plagued by the question of how many people don’t contemplate what it’s doing to their body. Many of these people don’t even realize they are an alcoholic and reside in a state of denial. It is these addicts that put me at unease because it may be too late before they realize what they have done through the years of continual inebriation.

There is a vast amount of research going on in the world of addiction. One of the research groups that John visits states, for those people whom ‘get a big kick from alcohol,’ they may be more predisposed to becoming an alcoholic due to a mutation in their genetic make up. It is possible that as much as 12% of white men have this mutation which puts them at risk for alcohol dependence. This doesn’t necessarily answer the, ‘why do I drink?’ but it may help to understand the dysfunction of relapse.

Toward the end of the documentary, John made a statement that pierced through my chest. Throughout the film he is searching for why alcohol is so addictive, and this is one of his thoughts along his journey. ‘An alcoholic isn’t just created overnight. It seems to take years of subtle, incremental changes. And that was really what happened in the case of my father. Changes occurred gradually over time, his drinking became more and more intensive, sustained and problematic. Nobody sets out to be an alcoholic and he certainly didn’t, it just happened.’

I’m sorry, but it appears that BBC has taken down the last 2 clips from this documentary. I am trying to find a full length version that can be posted. Also, if you know how, the documentary can be found on torrents.

As we already know, the liver has a LOT of functions, and these functions are vital to our survival. One of the largest jobs of a healthy liver is to produce enzymes required to metabolize particles in our blood stream. The purpose of this is to either break down molecules to forms that can be eliminated from the body (such is the case with alcohol and many other drugs/medications), or to change their original form to something that can be utilized by the body (such is the case with proteins like albumin and clotting factors). The liver also has many other functions, however, the components of breaking down and building molecules are the two most important when it discussing cirrhosis.

Cirrhosis is what occurs after repeated injury to the liver which destroys the normal, functional liver cells and replaces it with non-functional fibrosis, nodules and scar tissue. There are many causes of ‘repeated injury to the liver,’ which include alcohol intoxication, hepatitis viruses, autoimmune diseases and many others. Alcohol is the second leading cause of cirrhosis in the United States (the #1 cause is Hepatitis C).

As the liver loses its functional capacity, physical symptoms soon emerge. Some of the more notable symptoms are described below.

  • Jaundice – yellowing of the skin due to inability of liver to eliminate bilirubin from the blood stream
  • Itching – due to inability of liver to eliminate bile acids from the blood (there are other causes as well)
  • Bruising – due to inability of the liver to produce clotting factors
  • Spider angioma – small bruises on the body, due to elevated levels of estrogen that the liver is unable to break down
  • Confusion – due to inability of liver to break down and eliminate ammonia products from the blood
  • Asterixis – flapping of the hands when outstretched, also due to excess ammonia products
  • Varices – this is the biggest concern for doctors because it can lead to large amounts of blood loss in a short period of time. In cirrhosis, the liver becomes so scarred that even blood has a hard time passing through it, thus causing an increase of pressure in the vessels that travel to the liver. These vessels that are now carrying an increased pressure find a way to release it by either of two means: taking a different path in order to get around the liver, or by bursting open. Hence the concern.

The most important symptom that we will be talking about today is ascites. It is the progressive buildup of fluid in the abdominal cavity that may not be noticeable at first, but eventually leads to an accumulation so great that the abdomen becomes disproportionately larger than the rest of the body.

The cause of ascites can be difficult for some people to explain because it can be tricky and there is a bit of physics involved. However, the physics is simple if explained properly and the small fine details are easy to understand.

The fluid that enters the abdominal cavity gets there via two separate means that are both induced by cirrhosis.

  1. The cirrhotic liver loses the ability to produce proteins that are released into the blood stream and travel within the blood vessels of the body. These proteins in the blood cause a force on any fluid outside of the blood vessel to enter the vessel. Basically, the proteins act to pull fluid surrounding a blood vessel in to it. When the liver doesn’t produce these proteins, then you lose that pulling force as well.
  2. As we saw with varices, the liver becomes so scarred and fibrotic that the blood that normally passes through the liver freely can no longer do so. Thus, the blood vessels that travel to the liver become congested with blood that has nowhere to go. The increasing amount of blood within the vessels causes an increased pressure on its walls. Since the blood vessels have microscopic passages in the walls, the increased pressure causes the blood to leak out at a higher rate than normal

The fluid that leaks out of the blood vessels due to the elevation in pressure is not able to be reabsorbed because the liver is not producing the proteins that cause the pulling force on the fluid to reenter the blood vessels. This fluid accumulates in the abdominal cavity and becomes the physical sign/symptom of ascites.

This really only demonstrates a small fraction of how important the liver is to us. As I’ve seen with so many people before, many will disregard this subject because they don’t think it pertains to them. These are often the people at the greatest health risk. I have yet to learn how to get their attention.

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